Shared Decision Making in the Treatment of Psychosis

Shared Decision Making in the Treatment of Psychosis

There seems to be a disconnect between psychiatrists and their patients around prescribing antipsychotic medications in early-episode psychosis and schizophrenia: psychiatrists tend to prescribe antipsychotics, confident that they are essential, while patients discontinue them—often surreptitiously—at very high rates.1 The psychiatrists’ stance is understandable. Antipsychotics have repeatedly been demonstrated to improve positive psychotic symptoms. Moreover, the toxicity of these agents, particularly second-generation antipsychotics, is not grave over the short term. By diminishing positive symptoms, antipsychotics may help the patient preserve his or her social role and minimize the stigma associated with psychotic behavior. Moreover, the psychiatrist may fear a charge of malpractice if effective treatment is withheld. These ideas are reinforced by the day-to-day experience of real patients who experience improved outcomes.

Yet patients are often reluctant to take antipsychotics. Some say that the medications do not deliver the proffered benefits, that they make them feel as if something essential were deadened inside, and that they hate taking them. Many patients seem to feel that they were not involved in the decision-making process to begin medications and thus the prescription was not consensual. While there may have been discussion about which medications to use, the option of delaying or not taking them at all is rarely discussed.2 Initial experiences with antipsychotics are embittering for some patients and can harden their resistance to pharmacotherapy in general, which can seriously complicate treatment.

Eventually, some patients find salutary antipsychotics that are use-ful to their recovery; others seem to be caught in a cycle of prescription, nonadherence, and relapse. There is also a minority—not a large group but not insignificant—who do well without antipsychotics.3 It may be argued that at least some of these patients do well because they avoid antipsychotics.4

One way to improve this unsatisfactory misalignment between doctors and patients is to apply principles of shared decision making to whether and when to begin anti­psychotics, not just about which one to use. Shared decision making is a foundational principle of patient-centered care and a key element in the transformation of the mental health system. Increasingly, shared decision making is the gold standard in clinical practice. The Substance Abuse and Mental Health Services Administration (SAMHSA) has recently promulgated tools for practitioners, patients, and family supports in making shared decisions about all aspects of care, including whether to take psychiatric medications.5

A recent editorial in theBritish Journal of Psychiatry recommended offering patients a real option of deferring or avoiding antipsychotics in psychotic states.6 Psychiatrists vary in their eagerness to adopt such permissive practices; some believe that adherence is paramount and paternalism is often necessary to prevent loss of insight with consequent impaired judgment and functional decline. Our bias is to adopt a radically more collaborative style.

What new information does this article provide?

• Extends the use of shared decision making with people with psychosis to whether and when to use antipsychotic medications

• Raises critical questions about the underlying assumptions that lead to early and sustained use of antipsychotics

• Provides guidelines for collaborative shared decision making in psychotic states

• Provides principles for safety for patients, doctors, and others in delaying or minimizing antipsychotic medications

What are the implications for psychiatric practice?

If conditions for ensuring safety permit, entertaining shared decision making about whether and when to use antipsychotics may promote alliance and decrease polarization between doctor and patient.